PITFALLS

OPERATIVE PROCEDURE
1. Positioning, Incision and Exploration with Entrance
into the Lesser Sac
2. Transection of the distal margin and division of the
right gastric and gastroepiploic vessels
3. Ligation of the Left Gastroepiploic and Short Gastric
Vessels
4. Exposure and Isolation of The Gastroesophageal
Junction and The Left Gastric Vessels with Transection
of the Esophagus
5. Lymphadenectomy
6. Reconstruction
 1. Positioning, Incision and Exploration
with Entrance into the Lesser Sac

• Pitfall->Injury of the Middle Colic Vessels

– Consequence
• Result in segmental ischemia between the hepatic and
splenic flexure
• Transverse colon should be evaluated thoroughly
• Resection of involved colon if collateralization is poor
– Prevention
• When lesser sac is entered, omentum can be detached
from transverse colon with dissection of an avascular
plane
 2. Transection of the distal margin
and division of the right gastric and
gastroepiploic vessels
• Performed by staple
technique
• Pitfall:
– Duodenal stump
blow out
– Retained Gastric
Antrum
 3. Ligation of the Left Gastroepiploic
and Short Gastric Vessels
PitfallSplenic Injury and bleeding
• Repair: control bleeding with sponges and
gelfoam
• Prevention: Extensive gastric mobilization of
entire fundus and cardiavisualization of
posterior wall
 4. Exposure and Isolation of The
Gastroesophageal Junction and The Left Gastric
Vessels with Transection of the Esophagus
Pitfalls:
1. Damage of hepatic vein and left hepatic
artery
Visualization of the vessel through transparent
hepatogastric ligament is critical
2. Pneumothorax
Clear dissection of the pleura mediastinal during the
mobilization of esophagus
3. Esophageal perforation
Dissection should be performed away from esophagus
 5. Lymphadenectomy
• Performing D2 resection extensive
procedure(splenectomy and distal
pancretectomy)increase morbidity
 6. Reconstruction
• Pitfalls:
– Anastomosis leak and haemorrhage
– Post Gastrectomy Syndrome
• Afferent Loop Syndrome
• Efferent Loop Syndrome
• Anastomotic Stricture
• Roux Stasis Syndrome
• Bile Reflux Gastritis
• Dumping Syndrome
• Delayed Gastric Emptying
THANK YOU
 Duodenal Stump Blow Out
• Complication
– peritonitis and widespread sepsis
• Repair
– reexploration, primary repair with omental patch,
wide drainage of right upper quadrant and tube
duodenostomy
• Prevention
– modification of duodenal stump closure, tube
duodenostomy insertion
 Retained Gastric Antrum
• Complication
– Reccurent PUD or gastritis
• Repair
– Medical management via histamine receptor type
2 or PPI
• Prevention
– Transection of the duodenum extend 0,5 cm past
the pylorusvisualizing Brunner’s gland
 Reconstruction
Pitfall anastomosis leak
• Consequence:
– intra abdominal leak, peritonitis, sepsis, MOF and death
• Repair:
– Upper GI series or CT scan if developed unexplained fever
and tachycardia
– Insiation of antibiotic therapy and NGT insertion or
percutaneous drainage
– Persistence inflammation abdominal washout
• Prevention:
– Prevent risk factor for gastointestinal anastomosis leak
(malnutrition, weight loss, alcohol buse, smoking ,
contmination, long operative time 4-6 hours)
– Strong seromuscular suture
 Reconstruction
Pitfall anastomotic bleeding
• Consequence: hemorrhage and increased
transfusion requirement
• Repair: normally resolves spontaneously,
treated with correction of coagulopathy
• Prevention: careful inspetion and oversewing
of eposed staple lines
 Post Gastrectomy Syndromes
• Afferent Loop Syndrome
• Effernt Loop Syndrome
• Anastomotic Stricture
• Roux Stasis Syndrome
• Bile Reflux Gastritis
• Dumping Syndrome
• Delayed Gastric Emptying
 Afferent Loop Syndrome
• Consequence: present as unrelenting
epigastric painclosed loop
obstructionduodenal stump dehiscence
• Repair: Enteroenterostomy between afferent
and efferent loops
• Prevention: prevent risk factors (antecolic
reconstruction, antiperistaltic
gastrojejunostomy and poor positioning of
gastrojejunostomy
 Efferent Loop Syndrome
Associated primarily with internal hernia
• Consequence
– Present similr to small bowel obstruction with colicky
abdominal pain
• Repair
– Correction underlying problem (hernia reduction and
adhesiolysis)
• Prevention
– Proper closure of mesocolic defect and anchoring
jejunum to mesocolon
 Anastomotic Stricture
• Consequence
– Dysphagia (esophagogastrostomy stricture). Gastric
outlet obstriction (gastric to small bowel anastomosis)
• Repair
– Contrast study,esophagogastroduodenoscopy
– Endoscopic balloon dilatation
– Restaging due to recurrent tumor
• Prevention
– Conscious of blood supply during resection
– Largest possible end to end anastomosis stapler used
to create esophagogastrectomy
 Roux Stasis Syndrome
Presents 30% of patients with Roux en Y
gastrojejunostomy
• Consequence
– Early satiety, postprandial vomiting, epigastric pain
due to disconnection of transected roux limb
• Repair
– Treated with promotility agents (metoclopramide or
erithromycin)
– Endoscopy useful for dilating stricture
• Prevention
– Performing Uncut Roux en Y as initial recinstruction
Uncut Roux en Y
 Bile Reflux Gastriris
• Consequence
– Burning epigastric pain, bilous emesis,weight loss
• Repair
– Prokinetic agents, antispasmodic therapy,
cholestyramine, dietary modification
• Prevention
– Consider when choosing reconstruction
 Dumping Syndrome
Occur in 25% of patients
• Consequence
– Abdominal cramping and diarrhea
– hiperinsulinemia
• Repair
– Respond to medical management
– Low carbohydrate, high protein meals and fiber
supplementation
– Surgical (rare)reconstruction of pylorus
• Prevention
– No clear measure known to prevent dumping
syndrome
 Delayed Gastric Emptying
• Consequence
– Inability to tolerate oral diet (immedate)
– Pain, bloating, nausea, vomiting, weigh loss,
malnutrition (chronic)
• Repair
– Strictureendoscopic dilation
– Adhesivereoperation
• Prevent
– Careful dissection around the esophageal hiatus to
preserve vagal innervation